2.0 Analysis 2.1 Ingress of Water The sinking of the vessel precluded any structural examination and, consequently, the precise condition of the hull and deck at the time of the accident cannot be established. However, the survivor reported seeing some water leaking into the forward accommodation. It is not unusual for the seams of a 45-year-old wooden fishing vessel to experience some leakage due to working in a seaway. Further, given the vessel's history of shaft space flooding, it is likely that she was already experiencing some leakage. The fact that the vessel sank stern first and the engine-room bilge was reportedly dry would suggest that the leakage and accumulation of seawater was principally aft, in the lazaret and/or shaft space. 2.2 Circumstances Leading to the Sinking As the vessel was operating in following winds of up to 50kn and quartering seas of up to6m, large volumes of seawater were shipped on the afterdeck. The vessel was fitted with railings on the afterdeck which would allow water to rapidly drain off overboard. However, the shipped seas were such that a varying volume of seawater was continually on the afterdeck. The weight of the seawater would further aggravate the situation, progressively decreasing the vessel's already low after freeboard, causing the vessel to settle more by the stern. Because the custom-designed fish hold hatch covers were not used and the temporary plywood infill hatch cover was not battened down, shipped seawater most likely downflooded into the hold. The retention of shipped seas on deck and the downflooding led to progressive flooding, loss of reserve buoyancy, and the vessel sinking stern first. 2.3 Inflatable Liferaft and Safety Inflation of the Liferaft on Deck It is not known why the skipper inflated the liferaft on deck. This procedure was unsafe inasmuch as it left the liferaft vulnerable to damage. In this instance, however, it was fortuitous that the liferaft was inflated on deck because the conduit for the firing cable was kinked and several hard tugs on the painter were required to initiate inflation. Overcoming the difficulties associated with inflating the liferaft would have been much more difficult for the crew in the water. Method of Inflating the Liferaft Instances are on record where crew members have found themselves in the water without lifejackets before the liferaft could be launched or inflated. During abandonment, the cumulative effect of the anxiety resulting from the situation and the loss of valuable time associated with hauling the length of the painter to inflate the liferaft may decrease the survival time of a non-swimmer. The survivor expressed dissatisfaction regarding the time it took to haul on the long length of painter. An alternative and/or supplementary method of activating inflation of the liferaft, as is currently fitted on some liferafts, can prevent loss of valuable time and maximize the chances of survival of personnel. Issues Respecting the Capsizing of the Liferaft As the liferaft was fitted with small water pockets, it was more prone to capsizing in high winds and rough seas than liferafts fitted with larger water pockets. Although the new standards call for larger-size water pockets to enhance stability, existing liferafts were not required to be upgraded to meet the Canadian standards when these were introduced. The safety of personnel using older liferafts may be compromised because no limitation is placed on the life expectancy of liferafts and because vessels still carry liferafts which were manufactured before the new standards came into force. As the purpose of the entrance cover is to protect the liferaft occupants against the elements, it is imperative that the cover be closed. However, the liferaft capsized frequently, and the lone survivor was fearful of being trapped within the liferaft. Consequently, he had little option but to keep the liferaft entrance open to the detriment of his chances of survival. His exposure to the adverse weather conditions, in conjunction with the non-inflated liferaft floor, could account for the lone survivor's hypothermic condition when rescued some five and a half hours later. The cook's survival can be attributed to his immersion suit functioning satisfactorily. 2.3.1 MED Training and Survival Only the cook, who had undergone survival training, survived; the other two crew members, who had neither MED training nor survival training, did not. Although the cook's immersion suit was the only one in which the zipper functioned satisfactorily, his survival, nonetheless, can be attributed in great part to the survival training he had received--he was able to right the liferaft single-handedly a dozen times, and therefore could be sheltered partially from theelements. This occurrence once again highlights the need for MED training which includes survivaltechniques. 2.4 Immersion Suit and Safety The chances of survival of crews are increased by the carriage and wearing of survival suits. The Workers' Compensation Act of British Columbia requirement for the carriage of these suits, which extends beyond the requirements of TC Marine Safety, initiated a new practice among B.C. fishermen, that of taking personally owned immersion suits with them from vessel to vessel. This has created a problem in monitoring the maintenance of the suits, as they are moved from one vessel to another. The onus is on the skipper to ensure that the immersion suits are maintained in good working order. Because the suits are for use in emergency situations, and because there is no requirement for either servicing of the suits or for the crew to be trained in their care and maintenance, instances are on record where the suits have malfunctioned with tragic consequences. 2.5 Reason for the Distress Signals not Being Sighted the rescue vessels were operating in winds of up to 70kn and seas of up to 15m; they were subjected to heavy rolling and pitching; and they were shipping heavy seas and sprays; there were white foam patches on the seas; the height of eye above sea level of the crews on the rescue vessels was low; and the liferaft was at sea level and subjected to motion in high waves. The above factors would have substantially reduced the visibility from the bridge of the rescue vessels, and might account for the handheld flares not being sighted. 2.6 Action by the Regulatory Authorities 3.0 Conclusions 3.1 Findings Transport Canada (TC) Marine Safety was aware of the vessel's flooding, but did not inspect the vessel because it had not been notified of the 1995 repairs. The validity of Ship Inspection Certificates is contingent upon the liferafts being serviced annually, but TC Marine Safety has no regime in place to monitor compliance. The liferaft was made vulnerable to damage by being inflated on the foredeck. Valuable time was lost and difficulties were encountered in inflating the liferaft due to the length of the painter and the kink in the conduit for the firing cable. The 23-year-old liferaft carried on the vessel was fitted with small water pockets and was more prone to capsizing than more recent models of liferaft. A grandfather clause allows vessels to carry such liferafts. The cook single-handedly righted the liferaft, which capsized about a dozen times. The liferaft entrance cover was, of necessity, left open, thereby depriving the survivor of protection against the harsh conditions. The open entrance cover, the non-inflation of the liferaft floor, and frequent submersion of the survivor in seawater contributed to his hypothermic condition when he was rescued. The distress signals activated by the occupants of the liferaft went unnoticed, and some of the signals were lost overboard when the liferaft capsized. The survivor's ability to attract the attention of the rescue vessels was hampered when distress signals were lost overboard. The new practice of individuals carrying their own immersion suits from vessel to vessel has created a problem in monitoring the maintenance of these suits. The immersion suits, which are required to be used in an emergency, were stowed in the engine-room and not in a conveniently accessible location. Two of the three immersion suits previously had been submerged in salt water for some time, and their zippers were corroded and unserviceable. The immersion suits worn by the victims provided very little thermal protection. Neither the vessel nor the owners had any regime in place to ensure that the immersion suits were maintained in good order. The cook, the only crew member who had undergone survival training, survived; the other two did not. There is no regulatory requirement for the crew of fishing vessels of this size and type to undergo Marine Emergency Duties (MED) training. The cook's survival can be attributed to the donning and the proper functioning of the immersion suit and to his survival training. The cook, the only crew member who had undergone survival training, survived; the other two did not. There is no regulatory requirement for the crew of fishing vessels of this size and type to undergo Marine Emergency Duties (MED) training. The cook's survival can be attributed to the donning and the proper functioning of the immersion suit and to his survival training. 3.2 Causes The Hili-Kumproceeded to sea despite a storm warning broadcast, and was being operated in following high winds and rough seas with the fish hold hatch cover not battened down. The cumulative effect of large volumes of seawater shipped on the afterdeck, the vessel's low freeboard aft, and the flooding/downflooding of the below-deck spaces aft caused the vessel to settle by the stern, lose reserve buoyancy, and sink stern first. The hypothermia and subsequent drowning of two of the crew is attributable to the poor state of repair of their immersion suits and to their exposure to the harsh weather conditions when the liferaft capsized. 4.0 Safety Action 4.1 Action Required 4.1.1 Periodic Inspection of Liferafts Crew survival in emergency situations at sea depends to a large extent on the capability, reliability, and availability of survival equipment. Thus, the Life Saving Equipment Regulations require that inflatable liferafts on all vessels, including fishing vessels, be inspected and serviced annually. At present, there is no regime in place to ensure that liferafts receive the mandatory servicing. As revealed by the investigation into this occurrence, the liferaft on-board the Hili-Kum had not been inspected annually by a technician from an accredited service depot nor had this fact been monitored by Transport Canada (TC). This is not an isolated instance of non-compliance with the Life Saving Equipment Regulations. The Board previously expressed concern that the requirement to have liferafts serviced annually is frequently ignored and that the practice of many fishermen to have their liferafts tested only during the vessel's quadrennial inspection apparently is often tolerated by the regulatory authorities(9). Failure to perform the annual servicing may simply be an oversight because liferaft and vessel inspection cycles do not match, or it may be a result of owners/operators not viewing the liferaft inspection as being as necessary as repairs to the vessel or equipment required for day-to-day operations. The Board believes that failure to service liferafts annually permits defects to go undetected and uncorrected, thereby unnecessarily jeopardizing the crews'chances of survival in emergency situations at sea. Therefore, the Board recommendsthat: The Department of Transport implement procedures to verify that liferafts on all vessels including fishing vessels are serviced as required by the Life Saving Equipment Regulations. M97-01 Assessment/Reassessment Rating: Satisfactory Intent The design of the 23-year-old liferaft carried on the Hili-Kumwas such that the raft capsized several times; therefore, the entrance cover was left open, leaving the occupant exposed to the harsh environment. In a previous occurrence, the sinking of the tug PATRICIAB. McALLISTER, four crew members drowned and one died of hypothermia because the vessel carried an old liferaft which did not meet current design requirements. In its report on that occurrence, the Board recommended that the Department of Transport promote awareness of the limitations of older-type liferafts and encourage owners/operators to acquire appropriate replacements(10). In response, TC acknowledged that there is no legislation to force owners to replace older liferafts and that such liferafts will eventually be replaced due to old age. It further stated that TC Marine Safety promotes awareness among mariners of the limitations of older liferafts and encourages replacement with more modernmodels. To date, the Board is not aware of any specific action, other than the abovementioned, that would hasten the replacement of outdated liferafts. Moreover, the Board believes that the apparent widespread non-compliance with the one-year servicing requirement for liferafts is allowing older liferafts to remain on fishing vessels. Since many fishermen continue to rely upon outdated liferafts for their survival in the event of vessel abandonment, the Board recommends that: The Department of Transport set deadlines for the mandatory replacement of all liferafts failing to meet current standards. In the interim, the Board recommends that: The Department of Transport explore programs that would encourage owners/operators to acquire appropriate replacement liferafts prior to the established deadlines.